Nokea
A mother calls the nurse to her room because 'My baby's eyes are bleeding.' The nurse notes bright red hemorrhages in the sclerae of both of the baby's eyes. Which of the following actions by the nurse is appropriate at this time?
- A. Notify the pediatrician immediately and report the finding.
- B. Notify the social worker about the probable maternal abuse.
- C. Reassure the mother that the trauma resulted from pressure changes at birth and the hemorrhages will slowly disappear.
- D. Obtain an ophthalmoscope from the nursery to evaluate the red reflex and condition of the retina in each eye.
Correct Answer: C
Rationale: Subconjunctival hemorrhages are common and resolve spontaneously.
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A client is 1 day post-cesarean section with spinal anesthesia. Even though the nurse advised against it, the client has had the head of her bed in high Fowler's position since delivery. Which of the following complications would the nurse expect to see in relation to the client's action?
- A. Postpartum hemorrhage.
- B. Severe postural headache.
- C. Pruritic skin rash.
- D. Paralytic ileus.
Correct Answer: B
Rationale: High Fowler's position increases the risk of postural headaches.
A neonate is being admitted to the well-baby nursery. Which of the following findings should be reported to the neonatologist?
- A. Umbilical cord with three vessels.
- B. Diamond-shaped anterior fontanelle.
- C. Cryptorchidism.
- D. Café au lait spot.
Correct Answer: C
Rationale: Cryptorchidism (undescended testes) requires medical evaluation.
The nurse has provided anticipatory guidance to a couple that has just delivered a baby. Which of the following is an appropriate short-term goal for the care of their new baby?
- A. The baby will have a bath with soap every morning.
- B. During a supervised play period
- C. the baby will be placed on the tummy every day.
- D. The baby will be given a pacifier after each feeding.
Correct Answer: B
Rationale: Tummy time promotes motor development.
What percentage of weight loss did the baby experience? Calculate to the nearest hundredth.
- A. 5.55%
- B. 7.20%
- C. 6.85%
- D. 6.90%
Correct Answer: B
Rationale: Calculation: (3,278 - 3,042) / 3,278 * 100 = 7.20%
Which site should the nurse use to assess the pulse of a baby?
- A. Carotid.
- B. Radial.
- C. Brachial.
- D. Pedal.
Correct Answer: C
Rationale: Brachial pulse is easily accessible in infants.